Childhood abuse can occur as sexual, physical, and emotional abuse, but all forms of abuse can potentially cause anxiety, social function impairment, and posttraumatic stress disorder (PTSD). Although female children frequently experience more sexual abuse than male children, a meta-analysis on research papers in 22 countries found that the average prevalence of male sexual abuse is 7.9 percent (as cited in Hopton & Huta, 2012). Between 5 and 10 percent of children experience severe physical abuse, and 50 percent of them experience corporal punishment (Margolin & Vickerman, 2011). However, instances of childhood abuse are rarely reported, so only rough estimates are available.
/>
The detrimental effects of all types of direct abuse in children were linked to impaired brain development, feelings of helplessness, depression, substance abuse, anxiety-related problems, and PTSD (Shackman, Shackman, & Pollak, 2007; Margolin & Vickerman, 2011; Hopton & Huta, 2012). Traumatic events are not limited to direct childhood abuse. For example, inter-parental violence was also associated with the development of PTSD, and interviews in different settings show that anywhere between 13 and 50 percent of children who witnessed partner violence qualified for a PTSD diagnosis (Margolin & Vickerman, 2011). Therefore, both direct abuse and witnessing traumatic events in the domestic environment are associated with developmental issues that lead to developing anxiety and various other social disorders.
Abuse Outcomes
Certain gender differences are recorded in childhood abuse outcomes, but the detrimental consequences of childhood abuse occur regardless of the victims’ gender and are not predictable based on gender alone. However, symptom manifestation in abused children generally follows the same pattern. Various cognitive, behavioral, emotional, and psychobiological symptoms are present in abused children that result in impaired maturation and social development.
Gender Differences
Although females will more often experience social impairment and psychological disorders as a result of childhood abuse than males, the outcomes of childhood abuse are sometimes different between genders. While men will more often engage in suicide ideation, criminal behavior, and substance abuse, women will more likely display PTSD symptoms (Hopton & Huta, 2012). However, there is no clear distinction between the genders in term of predicting a definite trajectory of disorder development because men can show symptoms that warrant a clinical PTSD diagnosis (Hopton & Huta, 2012), and women can display aggressive behavior or have difficulties in managing depression symptoms (Cloitre, Chase Stovall-McClough, Miranda, & Chemtob, 2004).
Symptom Manifestation
In a study by Shackman et al. (2007), it was found that abused children will show increased voluntary attention to anger cues, and the response to facial expressions was highest when they were shown the image of their parents angry. Abused children will process anger cues they receive from the environment, which interferes with their attention and requires greater cognitive control for performing tasks. Problems with voluntary attention indicate lack of emotional regulation, and their involuntary attention allocation indicates excessive biases in processing information. Both issues were reported in abused children and associated with anxiety and aggression disorders (as cited in Shackman et al., 2007).
Excessive biases in abused children, which affect their involuntary attention allocation, are caused by the unpredictable nature of aggression in the family. Because aggression can arise at any moment, children with a history of domestic abuse or violence will often monitor their environment for threats, which is why their attention allocation and focus can suffer (Cloitre et al., 2004).
The lack of voluntary attention allocation results because the environment of abused children did not help them learn emotional regulation. While children are growing up, parents or caretakers are responsible for teaching them how to interpret emotional experiences, regulate their reactions, and act as role models to teach them mood regulation. Self-regulation is an important social skill, but growing up in an abusive environment proved to be associated with low interpersonal functionality and poor mood regulation abilities in adulthood, which can result in aggressive behavior, depression, and detrimental self-concepts (Cloitre et al., 2004).
No single diagnosis can be predicted in people that had experienced child abuse. However, PTSD is the most common diagnosis because domestic violence and child abuse are a common co-occurrence in approximately 40 percent of households in which adults with PTSD grew up (Margolin & Vickerman, 2011). The severity and frequency in both types of traumatic events are high, which causes the development of intrusive memories, negative associations with the home environment, and a variety of cognitive, behavioral, and emotional symptoms that are consistent with diagnostic criteria for PTSD.
However, the presence of PTSD also indicates the possibility of comorbid disorders. In abused children, depression, anxiety disorders, substance abuse, and PTSD are the most common disorders that exist simultaneously (Margolin & Vickerman, 2011). It is important to note that PTSD is usually the primary disorder and needs to be the focus of treatment in abused children or adults who were abused as children. Depression and anxiety disorder treatments in children are ineffective if domestic abuse or violence are the cause of their behavioral, cognitive, and emotional symptoms (Margolin & Vickerman, 2011). Studies also show that a misdiagnosis of another disorder, such as attention-deficit/hyperactivity disorder, may result in increased occurrences of PTSD symptoms (as cited in Margolin & Vickerman, 2011). Therefore, PTSD treatment for patients with a history of child abuse is the most effective way to alleviate intrusive memories and associated symptoms.
Treatment
Although Hopton and Huta (2012) found that group therapy for male adults who were abused as children showed significant improvements for 20 to 38 percent of participants according to the Impact of Events Scale and the Beck Depression Inventory (2nd ed.), group therapy is not considered effective. The unpredictable trajectory of disorder development in child abuse victims does not allow the therapists to utilize all the potential benefits of group therapy. Even though socializing with people who have had similar experiences proved effective in facilitating recovery, individual-centered therapy is more effective because traumatic events often result in comorbid disorders, which causes group incompatibility (Sloan, Bovin, & Schnurr, 2012).
Non-PTSD Cases
Even though PTSD can affect up to 50 percent of adolescents and adults who experienced childhood abuse, others may suffer from impaired social functions cause by other disorders, such as depression and anxiety. In those cases, symptom management and transforming maladaptive social behaviors is the main goal. Cognitive approaches, emotion-focused approaches, and interpersonal approaches are considered the best therapeutic strategies for reversing the impaired social functions in adults who grew up in an abusive environment. For example, childhood emotional abuse is associated with attachment anxiety and attachment avoidance in romantic relationships, and targeting those attachment systems to modify them and remove maladaptive interaction patterns (Riggs, Cusimano, & Benson, 2011).
PTSD as the Primary Disorder
The current first line of therapy in PTSD is exposure therapy because it was consistently effective in treating all types of PTSD and shows significantly higher adherence rates than other types of treatments (Hembree et al., 2003). Even though it is emotionally challenging, there are no documented exacerbations that resulted in worsening of PTSD symptoms or interfered with the accelerated recovery progress in patients (Rauch, Eftekhari, & Ruzek, 2012), and building a successful therapeutic alliance in the early stages of treatment can improve emotional regulation in child abuse victims during the intense interventions of exposure therapy (Cloitre et al., 2004).
Therapeutic Alliance
The strength of the patient-therapist relationship is the most important determinant of successful outcome, regardless of the type of disorder or treatment modality. However, the existing literature suggests that it is necessary to build a therapeutic alliance in the early stages of the treatment to maximize the probability of positive outcomes (as cited in Cloitre et al., 2004). The study by Cloitre et al. (2004) found that building a strong and positive therapeutic alliance during the initial stages of the cognitive-behavioral therapy, but the importance of strong therapeutic alliances is generalized to all treatments and types of disorders.
Conclusion
All forms of child abuse, including indirect exposure to domestic violence, can result in developmental impairment. Consequently, children and adolescents will have difficulties with affect regulation, attention allocation, negative self-concepts, maladaptive behavior, and anxiety in interpersonal relationships. Cases of severe and frequent abuse, in which children have low resilience levels to environmental stressors, can also result in PTSD development. Whenever present, PTSD should be treated as a primary disorder, despite the frequent comorbidities with depression and anxiety. Without PTSD, the treatments need to focus on managing symptoms caused by childhood abuse and modifying maladaptive behaviors. In both cases, building a strong therapeutic alliance early is a critical determinant of successful treatment outcomes.
References
Cloitre, M., Chase Stovall-McClough, K., Miranda, R., & Chemtob, C. M. (2004). Therapeutic alliance, negative mood regulation, and treatment outcome in child abuse-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 72(3), 411-416.
Hembree, E. A., Foa, E. B., Dorfan, N. M., Street, G. P., Kowalski, J., & Tu, X. (2003) Do patients drop out prematurely from exposure therapy for PTSD? Journal of Traumatic Stress, 16(6), 555–62.
Hopton, J. L., & Huta, V. (2012). Evaluation of an intervention designed for men who were abused in childhood and are experiencing symptoms of posttraumatic stress disorder. Psychology of Men & Masculinity, 14(3), 300-313.
Margolin, G., & Vickerman, K. A. (2011). Posttraumatic stress in children and adolescents exposed to family violence: I. Overview and issues. Cope and Family Psychology: Research and Practice, 1(S), 63-73.
Riggs, S. A., Cusimano, A. M., & Benson, K. M. (2011). Childhood emotional abuse and attachment processes in the dyadic adjustment of dating couples. Journal of Counseling Psychology, 58(1), 126-138.
Shackman, J. E., Shackman, A. J., & Pollak, S. D. (2007). Physical abuse amplifies attention to threat and increases anxiety in children. Emotion, 7(4), 838-852.
Sloan, D. M., Bovin, M. J., & Schnurr, P. P. (2012). Review of group treatment for PTSD. Journal of Rehabilitation Research and Development, 49(5), 689-702.
